The Impact of Hospital Capacity Strain: a Qualitative Analysis of Experience and Solutions at 13 Academic Medical Centers.

BACKGROUND: Hospital capacity strain impacts quality of care and hospital throughput and may also impact the well being of clinical staff and teams as well as their ability to do their job. Institutions have implemented a wide array of tactics to help manage hospital capacity strain with variable success. OBJECTIVE: Through qualitative interviews, our study explored interventions used to address hospital capacity strain and the perceived impact of these interventions, as well as how hospital capacity strain impacts patients, the workforce, and other institutional priorities. DESIGN, SETTING, AND PARTICIPANTS: Qualitative study utilizing semi-structured interviews at 13 large urban academic medical centers across the USA from June 21, 2019, to August 22, 2019 (pre-COVID-19). Interviews were recorded, professionally transcribed verbatim, coded, and then analyzed using a mixed inductive and deductive method at the semantic level. MAIN OUTCOME MEASURES: Themes and subthemes of semi-structured interviews were identified. RESULTS: Twenty-nine hospitalist leaders and hospital leaders were interviewed. Across the 13 sites, a multitude of provider, care team, and institutional tactics were implemented with perceived variable success. While there was some agreement between hospitalist leaders and hospital leaders, there was also some disagreement about the perceived successes of the various tactics deployed. We found three main themes: (1) hospital capacity strain is complex and difficult to predict, (2) the interventions that were perceived to have worked the best when facing strain were to ensure appropriate resources; however, less costly solutions were often deployed and this may lead to unanticipated negative consequences, and (3) hospital capacity strain and the tactics deployed may negatively impact the workforce and can lead to conflict. CONCLUSIONS: While institutions have employed many different tactics to manage hospital capacity strain and see this as a priority, tactics seen as having the highest yield are often not the first employed.

Inpatient clinician workload: a scoping review protocol to understand the definition, measurement and impact of non-procedural clinician workloads.

INTRODUCTION: Clinicians that care for hospitalised patients face unprecedented work conditions with exposure to highly infectious disease, exceedingly high patient numbers, and unpredictable work demands, all of which have resulted in increases in stress and burnout. Preliminary studies suggest that increasing workloads negatively affect inpatient clinician well-being and may negatively affect job performance; yet high workloads may be prioritised secondary to financial drivers or from workforce shortages. Despite this, the correlation between workload and these negative outcomes has not been fully quantified. Additionally, there are no clear measures for inpatient clinician workload and no standards to define ideal workloads. Using the protocol described here, we will perform a scoping review of the literature to generate a comprehensive understanding of how clinician workload of medical patients is currently defined, measured in clinical settings and its impact on the workforce, patients and institutional outcomes. METHODS AND ANALYSIS: We will follow the methodology outlined by Joanna Briggs Institute and Arksey and O'Malley to conduct a comprehensive search of major electronic databases including Ovid Medline (PubMed), Embase (Embase.com), PsycINFO, ProQuest Dissertations and Google Scholar. All relevant published peer-reviewed and dissertaion grey literature will be included. Data will be extracted using a standardised form to capture key article information. Results will be presented in a descriptive narrative format. ETHICS AND DISSEMINATION: This review does not require ethics approval though all included studies will be screened to ensure appropriate approval. The synthesis of this literature will provide a better understanding of the current state of work for inpatient clinicians, associated outcomes, and will identify gaps in the literature. These findings will be used in conjunction with an expert Delphi panel to identify measures of inpatient clinician workload to then guide the development of a novel workforce mobile application to actively track clinician work. We aim to lay the groundwork for future workforce studies to understand the optimal workloads that drive key outcomes for clinicians, patients and institutions.

The Predictive Potential of Elevated Serum Inflammatory Markers in Determining the Need for Intubation in CoVID-19 Patients.

Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients. Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model. Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.33.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort. Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.

Characterization of deciduous teeth stem cells isolated from crown dental pulp.

BACKGROUND/AIM: The last decade has been profoundly marked by persistent attempts to use ex vivo expanded and manipulated mesenchymal stem cells (MSCs), as a tool in different types of regenerative therapy. In the present study we described immunophenotype and the proliferative and differentiation potential of cells isolated from pulp remnants of exfoliated deciduous teeth in the final phase of root resorption. METHODS: The initial adherent cell population from five donors was obtained by the outgrowth method. Colony forming unit-fibroblast (CFU-F) assay was performed in passage one. Cell expansion was performed until passage three and all tests were done until passage eight. Cells were labeled for early mesenchymal stem cells markers and analysis have been done using flow cytometry. The proliferative potential was assessed by cell counting in defined time points and population doubling time was calculated. Commercial media were used to induce osteoblastic, chondrogenic and adipogenic differentiation. Cytology and histology methods were used for analysis of differentiated cell morphology and extracellular matrix characteristics. RESULTS: According to immunophenotype analyses all undifferentiated cells were positive for the mesenchymal stem cell markers: CD29 and CD73. Some cells expressed CD146 and CD106. The hematopoietic cell marker, CD34, was not detected. In passage one, incidence of CFU-F was 4.7 +/- 0.5/100. Population doubling time did not change significantly during cell subcultivation and was in average 25 h. After induction of differentiation, the multicolony derived cell population had a tri-lineage differentiation potential, since mineralized matrix, cartilage-like tissue and adipocytes were successfully formed after three weeks of incubation. CONCLUSION: Altogether, these data suggest that remnants of deciduous teeth dental pulp contained cell populations with mesenchymal stem cell-like features, with a high proliferation and tri-lineage differentiation potential and that these cultures are suitable for further in vitro evaluation of cell based therapies.